Russell, Telly R
Russell, Telly R is an individual health care provider with primary practice located at 26458 Maple Valley Black Diamond Rd Se Ste A , Maple Valley WA 98038-8350. He recently has 2 registered licenses in different health care specialties including Allopathic & Osteopathic Physicians / Hospitalist, Allopathic & Osteopathic Physicians / Family Medicine. Allopathic & Osteopathic Physicians / Family Medicine is his primary health care specialty. Russell, Telly R can be contacted via phone (425) 690-3465.Contact Information
Primary practice address
26458 Maple Valley Black Diamond Rd Se Ste A
Maple Valley WA 98038-8350
Phone: (425) 690-3465
Fax: (425) 690-9460
Website:
Health care specialties
| Specialty | Code | License # | State |
|---|---|---|---|
| Allopathic & Osteopathic Physicians / Hospitalist | 208M00000X | MD60403590 | Washington |
| Allopathic & Osteopathic Physicians / Family Medicine | 207Q00000X | MD60403590 | Washington |
Profile Details
| NPI number | 1780978338 |
|---|---|
| LBN Legal business name | Russell, Telly R |
| Credentials | Doctor of Medicine (MD) |
| Entity | Individual |
| Sole proprietor 1 | No |
| Enumeration date | May 31st, 2011 |
| Last updated | Mar 26th, 2020 - about 4 years ago |
1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.
Identifiers
| State | Type | Number | Issuer |
|---|---|---|---|
| All States | NPI | 1780978338 | NPPES |
| Washington | MEDICAID | 2020725 | |
| Washington | Other | G8930107 |
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